Timing It Right for a Claim Audit

[TFG Partners, LLC]

medical claims auditing have become essential for self-funded benefit plans, with many plans continuously monitoring their claim payments. If your organization hasn’t yet implemented this level of oversight, scheduling an annual audit can be a wise move, especially as you prepare for the coming fiscal year. Having updated data at your disposal can help forecast expected expenses, allowing for better financial planning. It also offers the opportunity to identify and recover any overpayments or errors from the previous year, positively contributing to long-term management.

With each annual audit, you can draw meaningful comparisons across different years, which can be invaluable for analyzing trends and anomalies in your claims data. This historical insight enables more effective oversight of your third-party administrator (TPA) for medical claims and your pharmacy benefit manager (PBM). While error rates are often low—typically in the single digits—the high costs associated with healthcare and pharmaceuticals mean that even minor errors can accumulate, resulting in significant financial losses. Also, timely claim audits are crucial for meeting regulatory requirements.

The complexity of medical billing and formulary management for Rx drugs can lead to oversights, even with the most experienced TPAs and PBMs. Auditors are trained to detect these errors, whether they’re recurring or isolated incidents. Addressing mistakes proactively is vital for making system improvements to prevent similar errors. While many employer-funded plans pursue audits as a cost management strategy, focusing on enhancing member benefits is paramount. Once you have a system for scheduled audits, you can focus on budgeting for the upcoming plan year.

Although it’s impossible to predict expenses with absolute certainty—an unpredictability that the recent coronavirus pandemic underscored—gaining a comprehensive understanding of your plan’s cash flow enhances your ability to make informed budget forecasts. Anticipate that healthcare costs will continue to rise annually; implementing measures to manage these expenses will positively impact your financial outlook. Ultimately, as you embark on the next plan year, accurate claims payments will contribute to a more efficient operational framework, reinforcing the value of regular audits as a management tool.
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